- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.06 / $167.06 / $192.12
| Facility | | $167.06 | $167.06 | $192.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.06 / $187.52 / $213.10
| Professional | | $167.06 | $187.52 | $213.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.83 / $170.48 / $170.48
| Facility | | $160.83 | $170.48 | $170.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $170.48
| Professional | | $170.48 | $170.48 | $170.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.52 / $225.89 / $304.73
| Facility | | $187.52 | $225.89 | $304.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $213.10
| Professional | | $170.48 | $170.48 | $213.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.85 / $488.85 / $488.85
| Professional | | $488.85 | $488.85 | $488.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.12 / $751.07 / $1,260.08
| Facility | | $533.12 | $751.07 | $1,260.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.57 / $204.57 / $213.10
| Professional | | $204.57 | $204.57 | $213.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $272.77
| Professional | | $170.48 | $170.48 | $272.77 |